Experts Share Tips for Optimizing Topical vs Systemic Therapies for AD

In a recent Dermatology Times Expert Perspectives custom video series, “Navigating Atopic Dermatitis Complexities and the Role of Topical Therapies,” Gina Mangin, MPAS, PA-C; Shanna Miranti, MPAS, PA-C; Omar Noor, MD; and Matthew Zirwas, MD, discussed a multifaceted approach to diagnosing and managing atopic dermatitis (AD), emphasizing personalized treatment plans incorporating topical and systemic therapies, from steroid-sparing options to biologics.

Diagnosis and Management

Mangin, a board-certified physician assistant at Sand Lake Dermatology Center in Orlando, Florida, shared insights into diagnosing and managing AD, emphasizing the importance of itch as a defining symptom. She distinguished AD from other papulosquamous disorders, emphasizing its relapsing course. A thorough patient history, including personal and family history of atopy (asthma, hay fever, food allergies), guides her treatment approach.

Mangin noted that environmental triggers vary by region. In Florida’s humid climate, sweating exacerbates symptoms, whereas cold air is a trigger for patients in northern climates. She also stressed the importance of reviewing skin care products, as fragranced soaps and detergents can worsen AD. When assessing chronic cases, she looks for excoriations, lichenification (particularly in patients with skin of color), and sleep disruption due to itching, which can indicate the need for more aggressive treatment.

Mangin defines treatment success as reduced reliance on topical steroids, lower itch severity scores, and decreased need for rescue corticosteroid injections. She also collaborates with patients to tailor treatment plans, considering their preferences regarding oral vs injectable therapies and the need for blood work.

“If I find that my patient is always using their topical steroid daily, that tells me we’re going to have to use something probably systemic, or something topically that’s much safer to use long term than a steroid cream. And we have tons of options out there now,” Mangin said.

Pediatric and Adolescent Patients

Miranti, a board-certified physician assistant at Riverchase Dermatology in Naples, Florida, reviewed strategies for treating younger patients with AD, focusing on newer, safer alternatives to traditional corticosteroids.

In terms of treatment, Miranti emphasized the expanding options for younger patients. Dupilumab (Dupixent; Sanofi and Regeneron) is approved for children as young as 6 months. Crisaborole, previously the youngest approved nonsteroidal option, is indicated for children 3 months and older but may cause stinging. Newer topical therapies include roflumilast cream 0.15% (Zoryve; Arcutis Biotherapeutics), approved for children 6 years and older, and tapinarof cream (Vtama; Dermavant/Organon), approved for children 2 years and older.

For adolescents, topical ruxolitinib cream (Opzelura; Incyte) provides rapid itch relief. Systemic options include JAK inhibitors for moderate to severe cases and biologics such as dupilumab, tralokinumab (Adbry; LEO Pharma), lebrikizumab (Ebglyss; Eli Lilly), which offer reduced injection frequencies—ideal for needle-phobic patients.

During treatment discussions, Miranti reassures patients and families that although therapies may be paused during remission, long-term management is necessary to maintain skin health and prevent severe flares. “Their skin barrier might be doing very well, and then something can completely derail the course of their disease. We have to be able to counsel patients that this is a roller coaster, and this is a chronic disease that we are going to have to continue treatment,” Miranti said.

Fast Relief

Noor, a board-certified dermatologist and co-owner of Rao Dermatology in New York, New York, discussed the role of topical ruxolitinib cream in managing AD. He emphasized that patients with AD present with a disrupted skin barrier, making topical therapy a key component of treatment, regardless of disease severity. For Noor, educating patients about their condition and the role of topical treatments in reducing inflammation and improving skin barrier function is crucial.

As a JAK inhibitor, ruxolitinib cream blocks inflammatory cytokines, providing rapid relief, sometimes as fast as within 15 minutes. Noor highlighted its steroid-sparing benefits, particularly for sensitive areas such as the face, neck, and eyelids. Many patients seek alternatives to topical steroids due to concerns about atrophy and striae. Ruxolitinib’s low systemic absorption minimizes safety concerns, and Noor advises patients to use it until their skin clears.

“Topical ruxolitinib cream has really advanced the efficacy options we have outside of topical corticosteroids,” Noor said. Beyond AD, he finds it effective for inflammatory conditions such as lichen planopilaris and lichen planus.

Topicals vs Systemics

Zirwas, a board-certified dermatologist at Bexley Dermatology in Ohio, discussed topical and systemic treatment strategies for AD. He noted that although topicals are effective, their use is limited by body surface area coverage. Zirwas typically reserves systemic treatments for patients with greater than 20% body surface area involvement, whereas those with 10% to 20% may benefit from either approach.

For hand eczema, Zirwas recommends using hair removal cream to enhance topical penetration. He also stressed the rapid itch relief provided by ruxolitinib cream, likening its efficacy to a hypothetical acne treatment that could clear breakouts within hours.

Regarding patient adherence, Zirwas prefers a simple regimen of weekday steroid application with weekend breaks. “That is, in my experience, the best adherence regimen because when we say, ‘Use it for 2 weeks and take a week off, or use it for a week and take a week off,’ patients aren’t keeping track of when they started using it,” Zirwas added.